PEDIATRICS 1 (LECTURE)

1B FLUID AND ELECTROLYTES

Dr. SANGGALANG |

P-05

Body Fluid Compartments Major Compartments For Fluids

 2/3 (65%) of TBW is intracellular (ICF) 1. INTRACELLULAR FLUID (ICF)
 1/3 extracellular water • Inside cell
 25 % interstitial fluid (ISF) • Most of body fluid here - 63% weight
 5- 8 % in plasma (IVF intravascular fluid) • Decreased in elderly
 1- 2 % in transcellular fluids – CSF, intraocular 2. EXTRACELLULAR FLUID (ECF)
fluids, serous membranes, and in GI, respiratory and • Outside cell
urinary tracts (third space) • Intravascular fluid - within blood vessels (5%)
• Interstitial fluid - between cells & blood vessels (15%)
• Transcellular fluid - cerebrospinal, pericardial, synovial

ELECTROLYTES IN BODY FLUID

COMPARTMENTS

METHODS OF FLUID & ELECTROLYTE

MOVEMENT
1. DIFFUSION
•Process by which a solute in solution moves
•Involves a gas or substance
•Movement of particles in a solution
•Molecules move from an area of higher concentration
to an area of lower concentration
•Evenly distributes the solute in the solution
•Passive transport & requires no energy*
2. OSMOSIS
•Movement of the solvent or water across a membrane
•Involves solution or water
•Equalizes the concentration of ions on each side of
membrane

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 PEDIATRICS 1 (LECTURE)
1B FLUID AND ELECTROLYTES
Dr. SANGGALANG |

P-05
•Movement of solvent molecules across a membrane to •Angiotensin II stimulates adrenal gland to release
an area where there is a higher concentration of solute aldosterone & causes an increase in peripheral
that cannot pass through the membrane vasoconstriction
3. ACTIVE TRANSPORT SYSTEM ISOTONIC SOLUTIONS
•Moves molecules or ions uphill against concentration • 0.9% Sodium Chloride Solution
& osmotic pressure • Ringer’s Solution
•Hydrolysis of adenosine triphosphate (ATP) provides • Lactated Ringer’s Solution
energy needed HYPOTONIC SOLUTIONS
•Requires specific “carrier” molecule as well as specific • 5% DEXTROSE & WATER
enzyme (ATPase) • 0.45% SODIUM CHLORIDE
•Sodium, potassium, calcium, magnesium, plus some • 0.33% SODIUM CHLORIDE
sugars, & amino acids use it
HYPERTONIC SOLUTIONS
4. FILTRATION •3% SODIUM CHLORIDE
•Movement of fluid through a selectively permeable •5% SODIUM CHLORIDE
membrane from an area of higher hydrostatic pressure •WHOLE BLOOD
to an area of lower hydrostatic pressure •ALBUMIN
•Arterial end of capillary has hydrostatic pressure > •TOTAL PARENTERAL NUTRITION
than osmotic pressure so fluid & diffusible solutes move •TUBE FEEDINGS
out of capillary •CONCENTRATED DEXTROSE (>10%)
ADH (Antidiuretic Hormone) ELECTROLYTES
•Made in hypothalamus; water conservation hormone
•Substance when dissolved in solution separates into
•Stored in posterior pituitary gland
ions & is able to carry an electrical current
•Acts on renal collecting tubule to regulate
•CATION - positively charged electrolyte
reabsorption or elimination of water
•ANION - negatively charged electrolyte
•If blood volume decreases, then ADH is released &
water is reabsorbed by kidney. Urine output will be •# Cations must = # Anions for homeostatsis to exist in
lower but concentration will be increased. each fluid compartment
•Commonly measured in milliequivalents / liter (mEq/L)
ALDOSTERONE •Na+: most abundant electrolyte in the body
•Produced by adrenal cortex
•K+: essential for normal membrane excitability for
•Released as part of RAA mechanism
nerve impulse
•Acts on renal distal convoluted tubule
•Cl-: regulates osmotic pressure and assists in
•Regulates water reabsorption by increasing sodium
uptake from the tubular fluid into the blood but regulating acid-base balance
potassium is excreted •Ca2+: usually combined with phosphorus to form the
mineral salts of bones and teeth, promotes nerve
RENIN impulse and muscle contraction/relaxation
•Released by kidneys in response to decreased blood
•Mg2+: plays role in carbohydrate and protein
volume
metabolism, storage and use of intracellular energy and
•Causes angiotensinogen (plasma protein) to split &
neural transmission. Important in the functioning of the
produce angiotensin I
heart, nerves, and muscles
•Lungs convert angiotensin I to angiotensinII
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 PEDIATRICS 1 (LECTURE)
1B FLUID AND ELECTROLYTES
Dr. SANGGALANG |

P-05
SODIUM/CHLORIDE IMBALANCES •Pretzels with salt
•Regulated by the kidneys •Pickles
•Influenced by the hormone aldosterone •Olives
•Na is responsible for water retention and serum •Soda crackers
osmolarity level •Tomato juice
•Chloride ion frequently appears with the sodium •Beef cubes
ion •Dill
•Normal Na = 135-145 mEq/L •Decaffeinated coffee
Low Sodium
•Chloride 95-108 mEq/L
•Fruit
•Na and CL are concentrated in ECF
- Fresh
Chloride
- Frozen
•Maintains serum osmolarity along with Na
- Canned
•Helps to maintain acid/base balance
•Unsalted Grains
•Combines with other ions for homeostasis; sodium,
- Pastas
hydrochloric acid, potassium, calcium
- Oatmeal
•Closely tied to Na
- Popcorn
•Decreased level is most commonly due to GI losses
- Shredded wheat
Sodium Functions •Fresh Meats
•Transmission and conduction of nerve impulses
MAJOR ELECTROLYTE IMBALANCES
•Responsible for osmolarity of vascular fluids
•Hyponatremia (sodium deficit < 130mEq/L)
•Regulation of body fluid levels
•Hypernatremia (sodium excess >145mEq/L)
•Sodium shifts into cells and potassium shifts out of the •Hypokalemia (potassium deficit <3.5mEq/L)
cells (sodium pump) •Hyperkalemia (potassium excess >5.1mEq/L)
•Assists with regulation of acid-base balance by •Chloride imbalance (<98mEq/L or >107mEq/L)
combining with Cl or HCO3 to regulate the balance •Magnesium imbalance (<1.5mEq/L or >2.5mEq/L)

Hyponatremia
Chloride Functions
•Excessive sodium loss or H2O gain
•Found in ECF
•Changes the serum osmolarity •Causes
•Goes with Na in retention of water –Prolonged diuretic therapy
•Assists with regulation of acid-base balance –Excessive diaphoresis
•Cl combines with hydrogen to form hydrochloric acid –Insufficient Na intake
in the stomach –GI losses – suctioning, laxatives, vomiting
–Administration of hypotonic fluids
Food Sources
–Compulsive water drinking
High Sodium
•Bacon –Labor induction with oxytocin
•Corned beef –Cystic fibrosis
•Ham –Alcoholism
•Catsup •Clinical Manifestations
•Potato chips -Headache

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 PEDIATRICS 1 (LECTURE)
1B FLUID AND ELECTROLYTES
Dr. SANGGALANG |

P-05
-Faintness -Flushed Skin
-Confusion -Dry mucous membranes
-Muscle cramping/twitching -Low UOP
-Increased weight -Tachycardia
-Convulsions -Seizures
Hyponatremia -Hyperactive deep tendon reflexes
•Assessment •Treatment
–Monitor for S/S in patients at risk - Low Na diet
- May use salt substitutes if K+ OK
-Muscle weakness
- Encourage H2O consumption
-Tachycardia
- Monitor fluid intake on patients with heart or renal
-Fatigue
disease
-Apathy
- Observe changes in B/P, and heart rate if hypovolemic
-Dry skin, pale mucus membranes - Monitor serum Na levels
-Confusion - Assess respiratory for crackles
-Headache - Weigh daily
-Nausea/Vomiting, Abdominal cramps - Assess skin and mucus membranes
-Orthostatic hypotension - Assist with oral hygiene
•Treatment - Check neurological status
-Restrict fluids - Teach patient to monitor I/O and watch for edema
-Monitor VS - Teach patient and family signs and symptoms and
-Monitor serum Na levels when to report them
-IV normal saline or Lactated Ringers - Safety precautions
-If Na is below 115, mEq/L hypertonic saline is ordered
-May give a diuretic for increasing H2O loss
-Encourage a balanced diet
-I/O
-Safety for weakness or confusion
-Assist with ambulation if low B/P
Hypernatremia
•Occurs with excess loss of H2O or excessive retention
of Na
•Can lead to death if not treated!
•Causes
–Vomiting/diarrhea
–Diaphoresis
–Inadequate ADH
–Some drugs
–Hypertonic fluids/tube feedings
–Major burns
•Signs & Symptoms
- Thirst
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 PEDIATRICS 1 (LECTURE)
1B FLUID AND ELECTROLYTES
Dr. SANGGALANG |

P-05
-Acute alcoholism
•Signs & Symptoms
-Anorexia
-N/V
-Drowsiness, lethargy, confusion
-Leg cramps
-Muscle weakness
-Hyperreflexia
-Hypotension
-Cardiac dysrhythmias
-Polyuria
•Treatment
- IV/PO Replacement
PO with 8 oz of fluid
Give K+ IV diluted in a large vein
* Never push K+ as a bolus *
Monitor site for infiltration
-Monitor patients at risk
-Monitor I/O
-Monitor EKG
-Monitor Serum K+
-Watch UOP
-Watch patients who take Digitalis for toxicity
-Teach family and patient dietary changes
Potassium Imbalances
•Potassium is the most abundant cation in the body
cells
•97% is found in the intracellular fluid
•Also plentiful in the GI tract
•Normal extracellular K+ is 3.5-5.3
•A serum K+ level below 2.5 or above 7.0 can cause
•cardiac arrest
•80-90% is excreted through the kidneys
Hypokalemia
•Causes
-Prolonged diuretic therapy
-Inadequate intake
-Severe diaphoresis
-Gastric suctioning, laxative use, vomiting Hyperkalemia
-Excess insulin •Greater then 5.0, EKG changes, decreased pH
-Excess stress •Results form impaired renal function
-Hepatic disease •Metabolic acidosis

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 PEDIATRICS 1 (LECTURE)
1B FLUID AND ELECTROLYTES
Dr. SANGGALANG |

P-05
•Acts as myocardial depressant; decreased heart rate,
cardiac output
•Muscle weakness
•GI hyperactivity
•Etiology
-Increased dietary intake
-Excessive administration of K+
-Excessive use of salt substitutes
-Widespread cell damage, burns, trauma
-Administration of larger quantities of blood that is old
-Hyponatremia
-Renal failure
•Signs & Symptoms
-Apathy Calcium
•Regulated by the parathyroid gland
-Confusion
•Parathyroid hormone
-Numbness/paresthesia of extremities
–Helps with calcium retention and phosphate excretion
-Abdominal cramps through the kidneys
-Nausea –Promotes calcium absorption in the intestines
-Flaccid muscles –Helps mobilize calcium from the bone
-Diarrhea
-Oliguria Hypocalcemia
•Abnormalities of the parathyroid gland or inadequate
-Bradycardia
intake or excessive losses
-Cardiac arrest
•Can cause skeletal and neuromuscular abnormalities
•Patient Monitoring •Impairs clotting mechanisms
-Monitor patients at risk •Affects membrane permeability
-Cardiac monitoring •Diagnostic findings
-Monitor pulse, rate and rhythm, and B/P –EKG changes
-Assess for hyperactive bowel sounds –Serum Ca++levels < 8.5 mg/dL
-Assess sensory and motor function –Prolonged PT and PTT
-Monitor neurological status •Etiology
-Medications -Surgically induced hypoparathyroidism
-Calcium gluconate IV may be give as an Renal failure
antidote -Vitamin D deficiency
-D50W and regular insulin to facilitate -Inadequate exposure to ultraviolet light
movement into the cells -Acute pancreatitis
-hyperphosphatemia
-Administer Kayexolate (oral and rectal)
-Dialysis •Signs & Symptoms
-Muscle cramps
-Hyperactive deep tendon reflexes
-Paresthesia of fingers, toes and face
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 PEDIATRICS 1 (LECTURE)
1B FLUID AND ELECTROLYTES
Dr. SANGGALANG |

P-05
-Tetany -Muscle weakness
-Positive Trousseau’s sign/Chvostek’s sign -Personality changes
-Laryngeal spasms -Nausea and vomiting
-Confusion -Extreme thirst
-Memory loss -Anorexia
-Cardiac dysrhythmias -Constipation
-Polyuria
•Patient Monitoring
-Pathological fractures
-Assess client’s at risk; surgery/transfusions
-Calcifications in the skin and cornea
-Seizure precautions -Cardiac arrest
-Administer IV Ca++ slowly; watch for infiltration •Diagnostic Findings
-Keep calcium gluconate at bedside -Serum Ca++ > 10.5 mg/dl
-Assess nutritional intake of Ca++ -Done changes on x-ray
-Watch for sensitivity if taking Digitalis, may cause lead -EKG changes
to cardiac arrest
•Patient Monitoring
-Monitor clients at risk; immobile, cancer
-Ambulate clients early
-Drink plenty of fluids, 3-5 liters to help excrete
excess Ca++
-Administer IV NS 200-500/hr if tolerated or for
moderate hypercalcemia
-Administer loop diuretics
-Administer Calcitonin
-Teach client to avoid dairy products

Hypercalcemia
•Increased serum levels of Ca++
•Symptoms are directly related to degree of elevation
•Clients with metastatic cancer are especially at risk
•Cause
–Excessive intake
–Excessive use of antacids with phosphate-binding
–Prolonged immobility
–Excessive vitamin D intake
–Thiazide diuretics
–Cancer
–Thyrotoxicosis

•Signs & Symptoms

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 PEDIATRICS 1 (LECTURE)
1B FLUID AND ELECTROLYTES
Dr. SANGGALANG |

P-05
-High dose steroid use
-Cancer chemotherapy

•Signs & Symptoms

-Cardiac dysrhythmias; hypotension/tremor
-Tetany
-Hyperactive deep tendon reflexes
-Positive Chvostek’s and Trousseau’s signs
-Memory loss
-Emotional lability
-Confusion
-Hallucinations
-Seizures
•Diagnostic Findings
-Serum Mg level < 1,5 mEq/liter
-Hypocalcemia
-Hypokalemia
-EKG changes

•Patient Monitoring
-Monitor clients at risk
-Watch for digitalis toxicity
Hypomagnesemia -Cardiac monitoring
•Excess Mg loss from renal or GI -Seizure precautions
•Insufficient dietary intake -Treat with oral, IM, IV or Mg salts
•Essential for neuromuscular integration; -Monitor urine output
hypomagnesemia increases muscle irritability and -Teach patients about foods high in Mg
contractility –Green vegetables
•Causes decreased blood pressure and cardiac –Nuts
dysrhythmias –Beans
•Often mistaken for hypokalemia, which can occur –Fruits
simultaneously
•Cause
-Excessive dietary intake of Ca++ or vitamin D
-Losses from gastric suctioning
-Severe nausea, vomiting or diarrhea,
-Pancreatitis, alcoholism
-Excessive diuretic therapy
-Administration of fluids without Mg
-Starvation
-Malabsorption syndromes
-Ulcerative colitis
-Hypercalcemia. Hypoaldosteronism
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 PEDIATRICS 1 (LECTURE)
1B FLUID AND ELECTROLYTES
Dr. SANGGALANG |

P-05
- EKG changes

•Patient Monitoring
-Monitor clients at risk
-Monitor VS, especially B/P
-Assess neuromuscular status
-Cardiac monitoring
-Be prepared to give Ca gluconate
-Minimize intake

Hypermagnesemia
•Usually results from renal failure
•Excessive intake
•Produces sedative effect on neuromuscular junctions,
diminishes muscle cell excitability
•Can cause hypotension or cardiac arrest
•Cause
-Renal failure
-Excessive use of Mg containing antacids
-Untreated diabetic ketoacidosis
-Hypoadrenalism

•Signs & Symptoms

-Lethargy and drowsiness
-Depress neuromuscular activity
-Depresses respiratons
-Sensation of warmth throughout the body
-Hypoactive deep tendon reflexes
-Hypotension
-Bradycardia
-Cardiac arrest
•Diagnostic Findings
- Serum Mg > 3mEq/liter

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